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More than just a headache

Headache and migraine are common reasons for primary care consultations, and pharmacists can play an important role in helping customers to understand their condition and advise on treatment.

More than 90 per cent of us will experience headache at some time, making it the most commonly reported symptom, according to NICE. Around one in seven people get migraines, with more than 10 million sufferers in the UK and over a billion worldwide making it the third most common disease, says the Migraine Trust.

“People suspecting migraine should be encouraged to see their GP for a review and diagnosis,” says Ria Bhola, headache nurse specialist at the Migraine Trust. “Obtaining a diagnosis is a crucial first step, which will determine if the person has a primary headache. A neurological assessment will help to eliminate any underlying secondary causes of their symptoms.” 

According to Kenny Chan, lead information pharmacist at Numark: “Almost everyone will suffer from headache or migraine at some point, and pharmacists are well equipped to help customers as the first port of call. There are many options for customers to try… it’s really important to assess each patient on an individual basis. Pharmacists should be asking questions about how long they have had a headache or migraine, is it their first one and how severe the pain is.”

The Migraine Trust estimates that 43 million days are lost from work and education each year in the UK because of migraine, while 71 per cent of sufferers say the condition affects their mental health. Migraine is two to three times more common in women – most likely due to hormonal factors as fluctuating oestrogen levels are a known trigger. Around 10 per cent of children get migraines, although the condition generally starts in puberty and peaks around the age of 35-40. 

The main symptoms include a throbbing headache (usually on one side) that worsens with movement; nausea, and sensitivity to light and/or sound. There are several stages, and recognising these can help sufferers decide when to take medication that can stop or shorten an attack. 

In the ‘premonitory’ or warning stage, people may feel tired and crave certain foods, or experience a stiff neck and mood changes. Around one in four sufferers experience the ‘aura’ stage, which may include visual disturbances, numbness or tingling for between five minutes and an hour. 

During the headache stage, patients experience moderate to severe pain made worse by moving around, with many reporting nausea or vomiting.

During the ‘resolution’ stage, the attack slowly fades; sleep usually helps with this. This is followed by the ‘recovery’ stage, during which a ‘hangover’ feeling can linger for hours or days. 

What causes migraine?

“Whilst not fully understood, it is known that during a migraine attack, the brain does not process sensory information correctly and this susceptibility is due to a combination of genetic and environmental factors,” says Bhola. 

Genetics are an important risk factor, with up to 60 per cent attributable to genes. Common triggers include lack of sleep, changes in the weather, alcohol, stress and excessive sensory stimulation. Foods containing tyramine, nitrates or monosodium glutamate can also act as triggers, as can caffeine. 

It’s helpful for customers to keep a migraine diary to help discover their triggers and the warning signs of an attack, recording factors like sleep, daily activities, menstrual cycle and any medications taken. 

Treating migraine

During an acute episode, simple analgesics help some sufferers. Opioids should be avoided as they can cause misuse and overuse headache. Anti-emetics are useful for treating nausea and help the body to absorb medication better. These include metoclopramide and domperidone. They should be taken before or alongside analgesics. Combination OTC medication includes paracetamol with caffeine or an anti-emetic.

Triptans reduce pain and nausea. They should be taken at the onset of the headache, and can be taken as tablets, nasal spray, injection or dissolvable tablets. 

Customers who get four or more migraines a month should be referred to their GP to discuss preventative medication. Those which a GP can prescribe include angiotensin blockers and ACE inhibitors, anticonvulsants, antidepressants and beta blockers. Calcitonin gene-related peptide antibodies are the first preventive medicines developed for migraine. These have to be prescribed by a specialist and are given as monthly or quarterly injections. Lifestyle advice includes keeping regular habits, particularly around sleep, meals and stress levels, as changes to a person’s environment are a common trigger. 

Common headache types

This is the most common type of headache, with a global prevalence of 42 per cent, according to BASH guidelines. They are more common in women and peak around age 25-40.

The pain is mild to moderate, bilateral and described as a tight band around the head. The headache lasts from several hours to several days. If there is headache on 15-plus days a month for at least three months, it is classed as chronic tension-type headache, which should be referred to a GP.

When distinguishing between TTH and migraine, Bhola says: “Migraine attacks are accompanied by associated features and tension-type headaches are largely ‘featureless’ headache.”

TTH is thought to be caused by stress, neck and jaw pain, disturbed sleep and possibly genetic factors.


Simple analgesics are usually effective. If these are not giving relief and headaches are severe, it is more likely to be a migraine. Opioids are not recommended due to the risk of dependency. There is a risk of developing medication overuse headache (MOH) if customers are taking analgesics on more than two days a week regularly; these customers should be referred to their GP. For chronic TTH, amitriptyline can help.

Self-help advice

“Balancing activities, having regular sleep, taking breaks and building relaxation and exercise into their routines can help,” says Bhola.

A cluster headache causes severe pain around the eye or temple and is always one sided, though it can switch sides. It’s also accompanied by one or more ‘cranial autonomic’ features: red/watery eye, runny nose/blocked nose, droopy eyelid, constricted pupil, flushing and facial sweating. It’s a rare condition affecting more men than women.

One of the key signs of cluster headache is restlessness. Attacks last from 15 minutes to three hours and typically occur once or twice a day. Simple analgesics are not effective; the main treatment is sumatriptan 6mg injection. 

“Cluster headache has cycles and bouts, so someone who has daily severe headache lasting one to three hours for weeks at a time that goes away for a year and comes back should make you think about cluster headache,” says professor Peter Goadsby, director of the NIHR Clinical Research Facility, Professor of Neurology at King’s College London and chairman of the charity OUCH UK.

“It’s really important for pharmacy staff to refer suspected cluster headache to their GP, and also the OUCH UK website for more information.”

This is a chronic headache disorder, where headache occurs on 15-plus days a month for at least three months. It affects as many as 20-50 per cent of chronic headache sufferers, with up to 70 per cent of chronic migraine sufferers affected.

Any type of analgesic can result in medication overuse headache, but triptans, opioids and combination analgesics will lead to more rapid development of MOH than simple analgesics.

Vinay Patel, services and contract pharmacist at Alphega, says: “The misuse of headache and migraine medication is increasingly becoming a problem. It’s important to challenge recurrent purchases, and pharmacy teams should endeavour to educate patients about the possibility of medication overuse headache.”

“Customers prescribed acute migraine medicines should be made aware of safe use and risks of developing MOH,” says
Bhola. “Reducing the number of acute treatment days is the aim for customers overusing medication. They may need support and advice on gradual versus abrupt withdrawal of the overused medicines.”

Views from the p3pharmacy panel

“Most customers will come to us first for advice about treating a headache as they won’t wait to see a GP for something that needs immediate relief. Common questions include how long should I take it for? Are there any side effects? When should I see my GP? Nurofen has long been a brand leader for us. Migraleve also does well, and Syndol is popular again. We suggest generic analgesics unless a customer asks for a branded product. GSL products can be on display, but many treatments are P lines. It’s important to have these at eye level behind the counter for customers to see.”

“This is a really big category for us, and it has become even more important in recent years. The most common questions we get asked are about which treatments work best and are the fastest acting. We also get a lot of requests for sumatriptan, and that’s increased a lot recently. Good sellers for us are Migraleve, Panadol and Nurofen Plus. It’s important to keep in a good variety of products, and especially some of the fast acting products. Also keep bottled water in stock for link sales for customers who want to take the medication straight away.”

“Most people ask what is the best or strongest medication to treat their headache – and it really isn’t about what is the strongest, but which medication is best for their symptoms. Everyone’s symptoms will be different, so we ask how intense the headache is, and is it tension, cluster or migraine? Some people can manage with regular OTC painkillers such as paracetamol, ibuprofen and co-codamol. The Migraleve brand sells well. Also, Migraitan is a great option for migraines. I’d say this category is more opportunistic, so ensure you have a variety of products available.”

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